[Oral anticoagulants adherence in elderly patients treated for atrial fibrillation in the era of direct oral anticoagulants]. / Observance du traitement anticoagulant oral chez le sujet âgé à l'ère des anticoagulants oraux directs.

BACKGROUND: The aim of this study was to determine the level of adherence to oral anticoagulants in the population of elderly patients treated for a non-valvular atrial fibrillation (AF) in the era of direct oral anticoagulants. PATIENTS AND METHOD: This transversal study used Morisky scale to assess adherence to oral anticoagulants. We also collected patients' reviews about the treatment and factors explaining a poor adherence. RESULTS: Between January and June 2015, 64 patients were included in Loire Atlantique. Average age was 77.8 years, CHA2DS2-VASc score was 4.06 and treatment (vitamin K antagonists [VKAs] in 78% patients) was prescribed since 4.3 years. According to Morisky scale, 84.4% of patients had a good adherence. There was 88% of good adherence with AVK versus 71% with direct oral anticoagulant, there was no statistically significant difference. The prescriber and the knowledge of anticoagulant treatment role seemed to be determinant factors. CONCLUSIONS: The level of adherence for oral anticoagulant appears higher than in most published studies. Diversification of therapeutic options could constitute an aid to personalize the prescription in order to improve it.

[A new index to evaluate arterial ageing independently of arterial blood pressure: pOpscore(®)]. / Un nouvel index pour évaluer le vieillissement artériel indépendamment de la pression artérielle : pOpscore(®).

AIM: Pulse wave velocity does not correlate to age in the upper limb but in the aorta and lower limb. We studied the link between ageing and pulse wave transit time (PWtt) indexes at the toe and finger. PATIENTS AND METHODS: Measurements were performed in 300 patients in occupational medicine and primary care after 5minutes supine rest using the device studied (pOpmètre(®), Axelife SAS, France). It measures transit time between R-ECG and finger or toe pulse signal (ttf or ttt respectively). We define as follows three indexes: difference between transit times: Dtf=ttt-ttf; pulse wave velocity PWVft=k*subjects height/Dtf (m/s); and the pOpscore(®) as the ratio of toe PWV/fingerPWV. RESULTS: Of the 300 tested patients, 147 were analysed using univariate correlation: age (P<10(-4)), SBP (P<10(-4)), DBP (P<0.02) and BMI (P<0.04) correlated to Dtf, PWVtf and pOpscore(®). Using stepwise regression analysis with Age, BMI, SBP, DBP, MBP: Dtf was dependent with age (P<10(-4)) and SBP (P<0.01); PWVtf with age (P<0.0001), SBP (P<0.01) and DBP (P<0.05); pOpscore(®) was dependent only to age (P<10(-4)). CONCLUSION: In this study, in contrast with the other vascular indexes studied dependent to age and blood pressure, pOpscore(®) was dependent only to ageing. pOpmètre(®) is a promising technique for routine determination of arterial stiffness and pOpscore(®) appears to be appropriate to study the structural vascular ageing in outpatient.

[Skull metastase masquerading as temporal arteritis: report of two cases]. / Métastase osseuse simulant une artérite temporale : à propos de deux observations.

INTRODUCTION: Temporal arteritis is the most common systemic vasculitis of the elderly. A definitive diagnosis is obtained on temporal artery biopsy examination (TAB). However, 30% of TAB yields false negative results. In such cases, diagnosis relies on clinical presentation and exclusion of alternative diagnosis. Conversely, false positive TAB are uncommon. CASE REPORTS: We report two patients who presented with headache, scalp tenderness and increased acute phase reactants, suggesting temporal arteritis, but which turned out to reveal a skull metastase. Temporal artery biopsy performed in one case demonstrated arterial wall inflammation. CONCLUSION: Clinicians must be aware that a skull lesion can mimick temporal arteritis.

[Screening of abdominal aortic involvement using Doppler sonography in active giant cell (temporal) arteritis at the time of diagnosis. A prospective study of 30 patients]. / Dépistage de l'atteinte aortique abdominale par échographie-doppler au diagnostic de maladie de Horton. Etude prospective de 30 patients.

BACKGROUND: Inflammatory involvement of extracranial large-sized arteries occurs in 10-20% of patients with giant cell (temporal) arteritis. Aortic involvement may reveal giant cell arteritis or occur as a late-onset complication, and represents one of the most serious manifestation of the disease with the risk of aortic dissection and/or aneurysm rupture. The thoracic aorta is more frequently involved but abdominal aortitis may also occur in giant cell arteritis. To date, few data are available about abdominal aorta changes at the initial stage of giant cell arteritis. PATIENTS AND METHODS: This prospective monocentric study was conducted between May 1998 and May 2002, and included 30 consecutive patients with biopsy-proven giant cell arteritis. Standard clinical and biological data were collected. Each patient underwent an abdominal aortic Doppler-sonography that looked for aneurysm, ectasia, thickening of the vascular wall, and hypoechoic halo around the aorta. RESULTS: Among the 30 patients of this study (25 women, 5 men, mean age 68.5 years), 4 (13%) had an abdominal aortic aneurysm, with a low diameter (23 to 27 mm), measuring 2 to 5.5 cm in length. A vascular wall thickening superior or equal to 3 mm was noted in 17 patients (68%). A 4 to 8 mm periaortic hypoechoic halo was found in 10 patients (33%). This halo was present in 3 out of the 4 patients with aneurysm. CONCLUSION: Aortic involvement is a potentially serious complication of giant cell arteritis. The question of a systematic screening of this complication remains open to discussion. Our study shows that Doppler sonography may detect morphological abnormalities on the abdominal aorta at the initial stage of giant cell arteritis. These abnormalities comprise mild aneurysms, thickening of the vascular wall and periaortic halo, which could correspond to inflammatory locations of the disease. Complementary studies are needed to assess their specificity and their seriousness.

[Horton's disease in elderly patients aged over 75: clinical course, complications of corticotherapy. Comparative study of 164 patients. Towards a reduced initial dose]. / Maladie de Horton du sujet âgé de plus de 75 ans: particularites évolutives, complications de la corticothérapie. Etude comparative sur une série de 164 patients. Vers une dose d'attaque réduite.

PURPOSE: Our study compares clinical and therapeutic courses (corticosteroid response, corticosteroid amount, complications) in people with giant cell arteritis before and over 75 years, during the first year of treatment. METHODS: A series of 164 patients was retrospectively analysed (mean age: 73.3 years) among the two subgroups: before 75 and over 75 years. Patient received (monitoring of reduction in the corticosteroid dosage) a 240 mg intravenous bolus of methylprednisolone followed by 0.5 or 0.7 mg/kg/d of prednisone, or 0.7 mg/kg/d of prednisone without the bolus. RESULTS: Corticosteroid response was identical for the two groups, before and over 75 (patients with corticoresistance: 15% vs 11.4%; NS) and giant cell arteritis-related complications were equivalent (n = 2 vs n = 2; NS). Corticosteroid load was slightly lower in the elderly group (cumulative dose of corticosteroids during the first year of treatment 5.2 g vs 5.8 g; P = 0.03). Patients with rheumatic side effects (collapses of vertebral bodies, mainly) were more frequent in the elderly group (15.5% vs 4.3%; P = 0.01), in spite of a limited mean follow-up period (10.7 months). CONCLUSION: Even if steroid response was identical in the therapeutic course of giant cell arteritis, rheumatic side effects appeared more frequent in the elderly group (over 75 years). In order to obtain a corticosteroid-sparing effect, new studies are necessary to evaluate a reduced initial dosage of corticosteroids.

A randomized, multicenter, controlled trial using intravenous pulses of methylprednisolone in the initial treatment of simple forms of giant cell arteritis: a one year followup study of 164 patients.

OBJECTIVE: (1) To evaluate the corticosteroid sparing effect of an initial intravenous (i.v.) pulse of methylprednisolone (MP) in the treatment of simple forms of giant cell arteritis (GCA). (2) To analyze corticosteroid response, steroid related side effects, and GCA complications. METHODS: Patients received a 240 mg i.v. pulse of MP followed by 0.7 mg/kg/day oral prednisone (Group 1) or 0.7 mg/kg/day prednisone without an i.v. pulse (Group 2, controls), or a 240 mg i.v. pulse of MP followed by 0.5 mg/kg/day prednisone (Group 3). Corticosteroid dosage was reduced after normalization of 2 biological inflammatory variables to obtain half-dosage after 4 weeks in Groups 1 and 2 and 20 mg/day after 2 weeks in Group 3. Tapering was systematically attempted from the 6th month of treatment. RESULTS: One hundred sixty-four patients were included in the trial (1992-96). Cumulative doses of corticosteroids after one year were identical for all groups (p = 0.39). No significant differences were observed in the time required for normalization of C-reactive protein, corticosteroid resistance (13.5%), and corticosteroid related side effects (39% of patients; p = 0.37). Corticosteroid resistant patients received larger doses and showed a high risk of GCA related complications (p = 0.02). CONCLUSION: MP pulses have no significant longterm, corticosteroid sparing effects in the treatment of simple forms of GCA and should be limited to complicated forms. Moreover, corticosteroid resistance is a real risk factor for GCA complications.

[Disclosure of Behcet disease by concomitant dental infection]. / Poussée inaugurale de maladie de Behçet concomitante d'un foyer infectieux dentaire.

BACKGROUND: Behçet's disease can be aggravated by chronic infection. Our case illustrates how the disease can be disclosed during an acute activation of a chronic infectious focus. CASE REPORT: A 40-year-old man had Behçet's syndrome associating fever, bipolar aphtosis, cutaneous pseudo folliculitis, anterior uveitis, and meningitis following an acute episode of a dental infection, with periapical granuloma. Antibiotic therapy was ineffective in calming this first flare-up of Behçet's disease. Corticosteroid and colchicine therapy were effective. DISCUSSION: Clinical and experimental work would implicat buccal streptococcal flora in the pathogenesis of Behçet's disease. Antibiotics offer interesting perspectives but further studies are needed to define their role in the treatment of Behçet's disease.

[Treatment of venous thromboembolic disease in the elderly]. / Traitement de la maladie thromboembolique veineuse chez le sujet âgé.

The incidence of deep vein thrombosis and pulmonary embolism is higher in the elderly due to the greater frequency of risk factors among this age group. Classic treatment with heparin and subsequently oral anticoagulant is still the most commonly used. Older patients may be at increased risk for anticoagulant-related bleeding for several reasons: increased anticoagulant effect of warfarin, increased prevalence of comorbidity and incidence of adverse drug reactions. As well as the usual contra-indications to such treatment, the psychological and physical well being of the patient must be assumed before an oral anticoagulant can be given. Careful prescribing is required: a low starting dose, a strict monitoring regime, for a limited duration. The indications for use of an inferior vena cava filter are wider in the older age group, not only for those in whom heparin is contraindicated, or has failed, but also for those who require treatment indefinitely with contra-indications to oral anticoagulant. Careful consideration of risk factors and the use of an individually designed prophylactic treatment are the best way to tackle this difficult problem in the elderly person.

[Extensive bone marrow necrosis and thrombotic microangiopathic anemia revealing disseminated adenocarcinoma]. / Nécrose médullaire extensive et anémie microangiopathique thrombotique révélant un adénocarcinome disséminé.

BACKGROUND: Bone marrow necrosis and thrombotic microangiopathy are uncommonly associated. We report an observation. CASE REPORT: A 52-year-old man with extensive bone marrow necrosis, associated with hemolytic microangiopathic anemia, was treated unsuccessfully with corticosteroids and plasmapheresis. Outcome was fatal. Autopsy showed disseminated bone marrow necrosis and medullary invasion by adenocarcinoma cells in this patient operated 13 years earlier for gastric cancer. DISCUSSION: Extensive bone marrow necrosis or thrombotic microangiopathy can complicate usually advanced cancer. Prognosis is poor without response to chemotherapy. Corticosteroids and plasma exchange are sometimes successful. A relative efficacy of treatment with staphylococcal protein A immunopheresis is reported by several authors in thrombotic microangiopathy.

[Principles of acute treatment of Horton's disease. Role of high-dose corticosteroid therapy]. / Les principes du traitement d'attaque de la maladie de Horton. Place des assauts cortisoniques.

Corticosteroid therapy, the elective treatment for temporal arteritis, can produce adverse effects on bone in this elderly population which usually occur late after acute high-dose administration. Such adverse effects are exceptional and generally have little impact as long as certain cortisone-sparing principles are followed: duration of acute treatments should be as short as possible; dosage can be tapered off rapidly, cutting the acute dose in half in 4 weeks; to titrate dosage, inflammatory proteins should be monitored (especially CRP because of its rapid kinetics and sometimes another protein with slower kinetics); this appears to be more useful for cortisone-sparing than the classical method based on clinical analysis and sedimentation rate; acute regimens should be accompanied by anticoagulation until figrinogen has returned to normal levels; clinical relapses during treatment are usually benign and can generally be controlled by raising the dose slightly; in case of failure due to an acute flare-up far from corticosteroid administration, it would be interesting to study the cortisone sparing effect of giving a 240 mg i.v. bolus of methylprednisolone followed by low-dose corticosteroids; if the relapse is only expressed in laboratory tests, holding the dose at same plateau for two weeks generally leads to spontaneous normalization. Intravenous bolus methlyprednisolone is well tolerated in this population of elderly patients. There is no recognized indication in the uncomplicated forms of temporal arteritis. The cortisone-sparing effect of this technique may result from the fact that the acute oral dose can be reduced. Complicated forms, particularly with ocular involvement, are recognized indications for bolus administration although the administration modalities have not yet been validated. In patients with overt ocular involvement, repeating emergency high-dose i.v. boluses every 6 to 8 hours warrants evaluation with the objective of recovering visual function.

[Trismus disclosing Horton's disease]. / Trismus révélant une maladie de Horton.

The authors report a giant cell arteritis case associating trismus and hemifacial oedema in a febrile context. After spontaneous regression of other manifestations, the apparition of more typical signs allowed to associate the diagnosis of temporal arteritis, later confirmed histologically. Thus, when facing a trismus case, even more when fever is present, it seems important to associate with the Horton's disease, no matter what the antecedents found at the interrogatory be, whether initial or isolated. The Doppler reveals flux abnormalities of the superficial branches of the external carotid. The examination of facial, temporal and internal maxillary arteries has a good negative predictive value in this pathology. It would be useful in therapeutic supervision.

[Fusaria infection in patients with neutropenia: apropos of 3 cases]. / Infection fusariale chez le neutropénique: à propos de trois observations.

The authors report three cases of fusarial infection in neutropenic patients with hematologic malignancies. The first patient was affected by a cutaneous extensive fusariosis. The second patient developed a fusarial lung infection during a multiple organ failure following allogenic bone marrow transplantation. The third patient who presented with refractory acute myelogenous leukemia, developed fusarial skin lesions, and died from pulmonary failure. The treatment of fusarial infection is disappointing and requires amphotericin B, in association with hematopoietic growth factors. The role of new agents, or combination chemotherapy remains to be determinated. The recovery of adequate neutrophil levels is the most important factor in the resolution of fusarial infection.

[Hematogenic bacterial endophthalmitis. A rare infection with very poor functional prognosis]. / L'endophtalmie bactérienne hématogène. Une infection rare au pronostic fonctionnel redoutable.

Three men and one woman (mean age 52 years) were admitted to hospital for septicemia (2 cases), sudden partial loss of visual acuity (1 case) and suspected conjunctivitis (1 case). Three of the patients showed risk factors (diabetes, alcohol intoxication, immunosuppression). Panophthalmitis (affecting all tunics of the eye) was apparent from the initial examination in all 4 cases (2 bilateral and 2 unilateral). Ocular involvement was associated with endocarditis and meningitis (pneumococcus) in 1 case, with nocardiosis (pulmonary, cerebral and nodal) in 1 case, and with septicemia with bacterial arthritis (Escherichia coli, streptococcus A) in 2 cases. Hemocultures were positive in 3/4 cases. The micro-organism was also detected in the joint (n = 2), urine (n = 1) and cerebrospinal fluid (n = 1), during pulmonary transparietal puncture (n = 1) and in intraocular biopsy tissue (n = 1). All patients received appropriate antibiotic therapy intravenously and intraocularly. The infection was cured in all cases, but with severe functional sequelae: blindness in 2 cases, and unilateral enucleation in the other 2 cases.

Description des données d'observation continue du comportement par une technique d'analyse de textes 1. Mise enévidence de styles individuels de maternage dans une lignée consanguine de souris.

This study illustrates the use of an original technique to give a precise description of the developmental environment provided by female mice to their pups, and of his changes with the age of the pups. Successive events recorded by continous observation of maternal behaviour of C57BL/6 inbred mice were analysed by a technique devoted to textual analysis. The different mothers were easily characterised by differences in the frequencies of the behavioural items expressed on the nest. These individual differences were stable with increasing age of the pups. On the other hand, the frequencies of behavioural sequences showed differences related to the age of the pups. The psychological meaning of some behavioural items is suggested by the results. The relevance of multivariate techniques of description directly applied on initial data of continous observation is discussed.

Description des données d'observation continue du comportement par une technique d'analyse de textes. 2. Comparaisons des conduites maternelles dans trois souches de souris.

This study illustrates the use of multifactorial analysis to perform comparisons between different genotypic groups, based on behavioral profiles. Maternal behaviour of C57BL/6 mice and of two reciprocal F2 was precisely described by continous observation. Unpolished data were directly analysed by a textual analysis technique using correspondences analysis. Strains were clearly different according to the relative frequencies of the different acts. These differences seemed to be related to grand-maternal effects, as previously shown in the same strains. Pups age related variation between day 2 and day 6 was very low when compared to maternal styles of the three strains.

Correspondances entre la variabilite des conduites maternelles et la diversification des comportements de la progeniture chez la souris.

Maternal behaviour may be used as a tool for hereditary transmission of behavioural characters in mammals. The maternal behaviour of mice from three different origins which reared foster pups of the same inbred strain was observed. Multivariate analysis revealed differences in maternal style related either to genotype effects or to grandmaternal influences. The behavioural development of the pups was studied at days 10, 14 and 17 for neuromotor coordination and spontaneous activity, at day 21, 40 and 75 for locomotor activity and food hoarding in a semi natural environment and at day 120 of age for water escape learning performance. Body weights were noted at the same ages. Results showed both maternal effects (differences between pups reared by an inbred or hybrid mother) and great-grandmaternal effects (differences between pups reared by two reciprocal F2's). An analysis of correspondences between mother and pup behaviour permitted the description of a large panel of correlations suggesting causal relations between maternal activities and pups characteristics. These maternal activities may be considered primarily as agents of hereditary transmission.

Comportements maternels chez la souris: Telle mere telle fille?

Relations between mother' and daughter' maternal behaviour were surched by continuous recording of locomotor activity and time spent in the nest during the first six days postpartum in two isogenic generations of mice. The first generation was composed of either heterozygous Fl or inbred C57BL/6 (=B6) dams, both giving birth after ovarian graft to B6 pups. In each litter the maternal behaviour of a female was studied in the same conditions as for her mother. Even in developing in quite different environments, both groups of B6 daughters did not differ for the behavioural patterns under study. Links between mother' and daughter' activity during the nursing period were shown in one group by important negative correlations suggesting a feedbak regulation mechanism. This illustrate a possible way of passive hereditary transmission of acquired behavioural characteristics.

Mise en evidence d'effects grand-maternels sur les conduites maternelles de la souris.

Continuous recording of locomotor activity and time spent in the nest were performed on mice during the five first days postpartum. We compared mice of the C57BL/6 inbred strain to mice of the two reciprocal F2's derived from the C57BL/6 and BALB/c parental strains. All animals reared foster pups of the C57BL/6 strain. The results did not show any difference between the three groups for the total amount of time spent in the nest ; this parameter decreases with days. No difference appeared between the C57BL/6 group and the F2 B6CxCB6 group (having a grandmother of the C57BL/6 strain), whereas each of these groups differed significantly from F2 CB6xB6C group (having a grandmother of the BALB/c strain) for the following indices : locomotor activity, mean duration of a stay in the nest, mean duration of an absence from the nest and percentage of nocturnal activity. These results are discussed in terms of grandmaternal effects as far as the variation in the strain of the grandmother is the only factor which can account for these differences in behavior.